< In the beginning, she had sloughing of moderate amounts of nipple
skin with pumping, and her nipple tips appeared quite dry despite the use
of Lansinoh and EBM.

She has very unusual nipple tissue which I have never encountered.  Her
nipple tissue is not dry as with her last baby.
The tips of her nipples are large and almost have the lined appearance that
a "Geographic tongue" does.>

Are you able to get close-up pictures? Please contact me privately, as I
have pictures I took once of a mom with some similarities to your
description. However, we were able to clear up the skin condition
prenatally, and I took before and after photos. Renate Reitveld of the
Netherlands recently contacted me when she had a patient with some of the
same description, after looking up my post on this mom in the archives.


< When suction of any type is exerted upon them
and her nipples elongate, the tips of her nipples appear to be constructed
of feathery villi-like appendages.>

It is so hard to judge from words alone. The "feathery-like appendages" I
think I once saw on a mother who had inverted nipples, and chose
to exclusively pump because of the whole unusual anatomy. This doesn't sound
anything like the everted nipples you are describing, though.


As far as elongating, or changing nipple size during pumping, see "The
Breastfeeding Atlas" by Wilson-Clay and Hoover  (p. 97??? I think) for an
illustration of the measurements they took before and after pumping on a
non-engorged mom. Such changes from vacuum have also been written up in
dairy animals. I think it would be very important to make sure the vacuum
was no higher than medium with sufficient "release" time, and only short
sessions with rests between.


< Pumping on low to moderate suction with
the Symphony and extra large flanges is comfortable for her>

This goes along with my observation that the choice of flange sizes is not
dictated wholly, or even mainly, by the size of the nipple circumference,
but by the depth of the milk sinuses, for vacuum attracts not milk, but
flesh, and the flange tunnel must be large enough for at least the middle of
the sinuses to compress themselves against it to yield milk. Too-small
flange tunnels simply focus 100% of the vacuum and subsequent
compression/tension on the skin, connective tissue, circulatory
and lymphatic vessels and their contents without drawing  the areola far
enough in to also attract the sinus area for compression. (Once again, I
declare that I reject the idea that there are no sinuses. I think the
concept of sinuses and their depth of placement is extremely important in
assessing problems before deciding on appropriate intervention/flange
sizes.)


< however, when we tried a Medela shield, the pain of the baby suckling was
excruciating
for her.>

If you mean the soft transparent shield, which size was used? I don't think
it was suction that was causing most of the pain. This sounds as if the
compression both of the baby's tongue/jaws and the firm rim at the base of
the shield nipple area was falling directly on the connective tissue of the
nipple, actually pinching/bruising it. Once again, I think the firm rim
inside of it may be acting like the pump flange tunnel in the way I just
explained that I visualize it.

< She reports that her nipples have always been somewhat tender,
even when she is not pregnant.>

I can personally identify with that, and I've heard lots of mothers say
that. So, in itself, that simply indicates to me that her normal anatomy has
placed the nerves in the nipple close enough to the surface that she
perceives pain more easily than someone whose anatomy has them buried deeper
inside. One reference I have on the microscopic anatomy of the nipple says
there are very few nerves on the skin of the nipple shank itself, but more
are buried deeper inside. However, I think there is a range of normal
variation. I might even go so far as to say that my "gut feeling" has always
been that some mothers just seem to have more pain nerves in their nipples
than others. Of the many, many prenatal nipple function assessments that I
have done over the years, I have noted that some mothers flinch when the
nipple is faintly touched, while others act as if there is virtually no
sensation even when the nipple "button" itself is touched much more firmly,
as in compression or tugging.

<She denies any itching or burning of her
nipples and the tissue is not reddened.>

You have said she is of African descent. I have always found it difficult to
detect skin redness, especially degrees, on many darker nipples, unless of
course there is actual skin damage.

My questions are: 1.)  Have you ever seen this type of nipple anatomy?
2.)What besides anatomical variation would cause the nipples to be this way?
3.) Can you think of any interventions that might help this Mom?

I once wrote a piece for a Florida newsletter on a "Zone" assessment tool I
thought up for early pospartum nipple pain, to judge if the pain is more
than "skin deep", and precisely where, within the 3 dimensional
nipple-areolar complex the site(s) are from which pain was emanating. This
was long before anyone began to define the concept of asymmetrical latch.
Not much call for it since off-center latch seems to correct so much
discomfort. If you are interested, contact me privately and I will try to
hunt it up.

<She is resigned to pumping with this baby also, but would really like a
name for what she is dealing with regarding the nipple anatomy.>

The name the pathologist gave when I sent him slides of sloughed off skin
from the patient I mentioned above was "keratosis".  However, the pain
description etc. that you are giving leads me to believe there is more to it
than that.

Once again, I encourage you to get close-up pictures, which are often better
than a thousand words.

Jean
******************
K. Jean Cotterman RNC, IBCLC
Dayton, Ohio USA

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